Patient Resources

We believe your care should be simple, seamless, and stress-free. To help you prepare for your visit, we provide all the necessary forms and resources online. Please complete the required documents before your appointment with Jordan River Women’s Health. This allows our team to focus on what matters most, you and your health.

Authorization for Release of Medical Information Form

"*" indicates required fields

JORDAN RIVER WOMEN’S HEALTH, P.C.

Denise Nippert, MD
Le-Hai Austin, APRN

Authorization for Release of Medical Information

Patient Name*

Date*

Social Security Number:*

DOB:*

Address:*

Apt.

City:*

State:*

Zip:*

This is to authorize the release of medical information regarding the above identified person.

From or To:

Physician/ Clinic:*

Phone*

Fax:*

Address:*

City:*

State:*

Zip:*

From or To:

Jordan River Women’s Health

3584 W. 9000 S. Suite 206 West Jordan, UT 84088
Ph: (801) 561-2227 Fax: (801) 561-5353

*Please note: Releases without either a phone number or an address cannot be processed.

Information to be released:*

Date Range:

Date From:*
MM slash DD slash YYYY

Date To:*
MM slash DD slash YYYY

Reason for Transfer:*
Permanent Transfer
Continuation of Care
Second Opinion

Dissatisfied*

I Acknowledge and hereby consent to such that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results andkor AIDS information*

This Authorization is valid for ISO days from date of signing and may be revoked at any time by sending a written request to Jordan River Women’s Health, P.C. prior to the expiration date. Any such withdraw will not aaect any information or records disclosed prior to written notice of withdraw.

I understand that authorizing disclosure of my protected health information is voluntary and that I need not sign this authorization in order to assure medical treatment. I further understand that the disclosure of this information carries with it the potential for unauthorized redisclosure and the information may no longer be protected by Federal conndentiality rules.

Signature of Patient or Legal Representative*

Relationship to Patient

Print Name*

Email*

Date*
MM slash DD slash YYYY

CAPTCHA

Comments
This field is for validation purposes and should be left unchanged.

OB/GYN Care in West Jordan

Women’s Health You Can Trust

Your well-being deserves compassionate, personalized care. At Jordan River Women’s Health, we’re here to support you through every stage of life—from routine exams to advanced treatments.
Take the next step in your health journey today.

Request an Appointment

Mail Us

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Patient Resources

Authorization for Release of Medical Information Form

JORDAN RIVER WOMEN’S HEALTH, P.C.

Denise Nippert, MD
Le-Hai Austin, APRN

Authorization for Release of Medical Information

This is to authorize the release of medical information regarding the above identified person.

From or To:

From or To:

Jordan River Women’s Health

3584 W. 9000 S. Suite 206 West Jordan, UT 84088
Ph: (801) 561-2227 Fax: (801) 561-5353

*Please note: Releases without either a phone number or an address cannot be processed.

Date Range:

OB/GYN Care in West Jordan

Women’s Health You Can Trust

Contact Details

Other Links

Request an Appointment

Mail Us

Call Us

Patient Resources

Authorization for Release of Medical Information Form

JORDAN RIVER WOMEN’S HEALTH, P.C.

Denise Nippert, MDLe-Hai Austin, APRN

Authorization for Release of Medical Information

This is to authorize the release of medical information regarding the above identified person.

From or To:

From or To:

Jordan River Women’s Health

3584 W. 9000 S. Suite 206 West Jordan, UT 84088Ph: (801) 561-2227 Fax: (801) 561-5353

*Please note: Releases without either a phone number or an address cannot be processed.

Date Range:

OB/GYN Care in West Jordan

Women’s Health You Can Trust

Contact Details

Other Links

Request an Appointment

Denise Nippert, MD
Le-Hai Austin, APRN

3584 W. 9000 S. Suite 206 West Jordan, UT 84088
Ph: (801) 561-2227 Fax: (801) 561-5353